Medicare Reimbursement Of Dialysis Chair For Home Dialysis

[hatedialysis2]

When I switched to home hemo  in 2013, my clinic told me that the chair was my responsibility and it had to be a trendel chair.  The article below says that its the clinic's responsiblility.   Did anyone else have to pay for their dialysis chair?

http://forums.homedialysis.org/threads/3174-medicare-reimbursement-of-dialysis-chair-for-home-dialysis

[Bill Peckham]

I bought my own chair because I found the one supplied by unit to be uncomfortable but my unit does provide their standard incenter chair to people using HHD. I don't think it is an open question, the unit has to provide a chair but it doesn't have to be a comfortable one.

[cattlekid]

I am interested to hear that you had to have a trendel chair to dialyze at home.  I dialyzed in a standard recliner.  My HHD nurse didn't say boo when she did my home visit.

[hatedialysis2]

Thank you BP and CK for your replies.  I have a feeling my nurse at the time did not know that he clinic supplies the chair.  The recliner chair I bought does recline back but not completely flat which I could not afford to buy but close enough I guess.   I am now considering nocturnal and would definitely need a different chair or a reclining mattress.

[Charlie B53]

I read through that link as well as a couple of related Medicare/CMS Rules.   Each Clinic IS responsible to provide an approved recliner for home hemo, but NOT for nocturnal home hemo as the Dept figures Nocturnal is done in bed and no need then for a chair that will tilt horizontal.

If you want a chair better get it before you start training for Nocturnal.


I also found a section on Drugs and Medications that very clearly spells out Phosphorus binder ARE INCLUDED.

I will be copying this subsection 20.3 and stirring up the crock pot as Clinics are claiming they are NOT included.  Fortunate for me my co=pay through the VA is cheap, but I know for many of you is is quite expensive.   Clinics are going to balk at being forced to provide binders.   Oh well.  It is clearly written.

[Hootie]

On the chair....we asked for one and saw those hard in center chairs that were offered and decided to go the lazy boy route. They have a chair that is great for dialysis. It's somewhat expensive but my if you are in the chair for his for hours  then it's worth it.

Great news on the binders. I would like the link to share with my center. We just started the binders. Wife did not want pills that the plan would over 400 dollars per month for...she wanted renvela powder...that cost the plan almost $1500 per month. Medicare part D with UHC. Needless to say donut hole almost shot in April. That drug cost a significant amount of money.

Trying to see what Davita is going to do...

[Simon Dog]

I also found a section on Drugs and Medications that very clearly spells out Phosphorus binder ARE INCLUDED.

Can you provide a link to the policy?

The best procedure is to file a formal grievance with your clinic.  By policy, they have to give you a written response - and will be less likely to blow you off with inaccurate nonsense.

[Zach]

I also found a section on Drugs and Medications that very clearly spells out Phosphorus binder ARE INCLUDED.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/

See Outlier Policy:
"… Implementation of ESRD-related oral-only drugs, that is oral drugs that do not have an injectable equivalent, has been delayed until January 1, 2024."

[SutureSelf]

I also found a section on Drugs and Medications that very clearly spells out Phosphorus binder ARE INCLUDED.

I will be copying this subsection 20.3 and stirring up the crock pot as Clinics are claiming they are NOT included.  Fortunate for me my co=pay through the VA is cheap, but I know for many of you is is quite expensive.   Clinics are going to balk at being forced to provide binders.   Oh well.  It is clearly written.

What you read was either outdated or misinformation.  From a CMS FACT SHEET provided by the Natioanl Renal Administrators Association web site:

FACT SHEET

FOR IMMEDIATE RELEASE
October 29, 2015

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

CMS Updates to Policies and Payment Rates for End-Stage Renal Disease Facilities for CY 2016 and Changes to the ESRD Quality Incentive Program
Finalized Payment System

OVERVIEW: On October 30, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2016.

The ESRD final rule is one of several rules for calendar year 2016 that reflect a broader Administration-wide strategy to provide quality care at lower cost by improving ways to deliver care, pay providers, and use information. Provisions in these rules are helping to move our health care system to one that values quality over quantity and focuses on reforms such as measuring for better health outcomes, focusing on disease prevention, helping patients live successfully at home, helping manage and improve chronic diseases, and fostering a more efficient and coordinated health care system.

This final rule also includes changes to the ESRD Quality Incentive Program (QIP) for payment years (PYs) 2017-2019 under which payment incentives are made to dialysis facilities to improve the quality of dialysis care. Under the ESRD QIP, facilities that do not achieve a minimum total quality performance score receive a reduction in their payment rates under the ESRD PPS.

ESRD PPS BACKGROUND: Section 153(b) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended the Social Security Act (the Act) to require CMS to implement a bundled PPS for renal dialysis services furnished to Medicare beneficiaries for the treatment of ESRD effective January 1, 2011. The bundled payment under the ESRD PPS includes all renal dialysis services furnished for outpatient maintenance dialysis, including drugs and biologicals (with the exception of oral-only ESRD drugs until 2025) and other renal dialysis items and services that were formerly separately payable under the previous payment.....


EDIT:  Sorry, Zach.  Didn't mean to step on your toes.  I should have read the complete thread.   

[Charlie B53]

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c11.pdf

This publication is dated 1/13/16

Subsection 20.3   (Note:  I don't have Word on this machine so copying and pasting I lose formatting).

All  drugs and biologicals  used for the treatment of ESRD are included  in the ESRD P P S
and are not separately paid  as of January 1, 2011.   The drugs and biologicals  include  but
are not  limited  to:
•
Drugs and biologica ls
included  under the composite  rate as of December 31,  2010
(discussed  below);
•
Former separately billable  Part B injectable  drugs;
•
Oral or other forms of injectable  drugs used for the treatment of ESRD formerly
billed  under  P art D; and
•
Oral or other forms  of  drugs  and  biologica ls   without   an  injectable   form. 
(Implementation   delayed  until   January  1,  2016.)

(Note: part way down is a boxed chart which specifies)

Bone and Mineral Metabolism
Drugs used to prevent/treat bone disease secondary to dialysis.   This  category includes  phosphate binders  and calcimimetics.

It is clear to me by the date of this publication that the intent is to cover these binders, however, viewing the 'included' list of billable items at

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Downloads/CY-2016-ESRD-PPS-CONSOLIDATED-BILLING-LIST-Effective-1-1-2016.pdf

I find most everything EXCEPT any form of binders.

So the question is "Is this an error on the part of CMS when drafting the 'Included 'List?

[SutureSelf]

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c11.pdf

This publication is dated 1/13/16

Subsection 20.3   (Note:  I don't have Word on this machine so copying and pasting I lose formatting).

All  drugs and biologicals  used for the treatment of ESRD are included  in the ESRD P P S
and are not separately paid  as of January 1, 2011.   The drugs and biologicals  include  but
are not  limited  to:
•
Drugs and biologica ls
included  under the composite  rate as of December 31,  2010
(discussed  below);
•
Former separately billable  Part B injectable  drugs;
•
Oral or other forms of injectable  drugs used for the treatment of ESRD formerly
billed  under  P art D; and
•
Oral or other forms  of  drugs  and  biologica ls   without   an  injectable   form. 
(Implementation   delayed  until   January  1,  2016.)

(Note: part way down is a boxed chart which specifies)

Bone and Mineral Metabolism
Drugs used to prevent/treat bone disease secondary to dialysis.   This  category includes  phosphate binders  and calcimimetics.

It is clear to me by the date of this publication that the intent is to cover these binders, however, viewing the 'included' list of billable items at

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Downloads/CY-2016-ESRD-PPS-CONSOLIDATED-BILLING-LIST-Effective-1-1-2016.pdf

I find most everything EXCEPT any form of binders.

So the question is "Is this an error on the part of CMS when drafting the 'Included 'List?

You didn't read far enough.  Section D. from the CMS Regulations and Requirements link you provided:

D. Oral Forms of Non-Injectable Drugs
Oral forms of non-injectable renal dialysis drugs and biologicals will be included in the ESRD PPS as a Part B renal dialysis service.
NOTE:Implementation of renal dialysis oral-only drugs has been delayed until January 1, 2024. - EDIT: This includes phosphorus binders.

Secondly, larger pharmacies like CVS, Costco, Walmart, etc. are very well aware of what would or would not be allowable charges under Medicare part D drug plans and supplied by dialysis clinics.  A year or so ago my part D drug plan refused to pay for EMLA cream with the rationale that it was now included in the bundled rate and should be supplied by the dialysis facility - which it was, although a generic.  However, I still had the option of paying out of pocket for the brand name if so wishing.

[Charlie B53]

Qwap!    I thought I was on to something.   Alas, just one more proof that whatever a 'Guy' thinks, he is wrong.   At least according to my Wife!